Sanjeev Arora M.D., FACGProfessor of Medicine

Executive Vice ChairmanDepartment of Medicine

University of New Mexico School of Medicine

MISSION

The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.

Supported by Agency for Health Research and Quality grant 1 UC1 HS015135-03 and New Mexico Legislature

MISSION

Underserved Area for Healthcare Services

Rural New Mexico

• 121,356 sq miles• 1.83 million people• 42.1% Hispanic• 9.5% Native American• 17.7% poverty rate

compared to 11.7% nationally

• >22% lack health insurance

• 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA’s)

• 14 counties designated as Health Professional Shortage Areas (HPSA’s)

RURAL NEW MEXICO

HEALTHCARE IN NEW MEXICO

~20% practice in rural or frontier areas

New Mexico Physician Survey 2001

HEALTH CARE IN NEW MEXICO

HEPATITIS C IN NEW MEXICO

~ Estimated number is greater than 32,000

~ Less than 5% have been treated

~ Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths

~ 1978 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated

~ Highest rate of chronic liver disease/cirrhosis deaths in the nation

HEPATITIS C IN NEW MEXICO

GOALS

~ Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes

~ Develop a model to treat complex diseases in rural locations and developing countries

GOALS

PROJECT ECHO

~ University of New Mexico School of Medicine Dept of Medicine and Telemedicine

~ NM Department of Corrections~ NM State Health Department

~Indian Health Service

~Community Providers with interest in Hepatitis C and Primary Care Association

PARTNERS

METHOD

~ Use Technology (telemedicine and internet) to leverage scarce healthcare resources

~ Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices”

~ Case based learning: Co-management of patients with UNMHSC specialists

~ Centralized database HIPAA compliant to monitor outcomes

METHOD

STEPS

~ Train providers, nurses, pharmacists, educators in Hepatitis C

~ Install protocols and software on site

~ Conduct telemedicine clinics – “Knowledge Network”

~ Initiate co-management – “Learning loops”

~ Collect data and monitor outcomes centrally

~ Assess cost and effectiveness of programs

STEPS

COMMUNITY PARTNERS~ No cost CME’s and Nursing CEU’s

~ Professional interaction with colleagues with similar

interest – Less isolation with improved recruitment and retention

~ A mix of work and learning ~ Obtain HCV certification

~ Access to specialty consultation with GI, hepatology,

psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator

BENEFITS TO RURAL PROVIDERS

DISEASE SELECTION

~ Common diseases

~ Management is complex

~ Evolving treatments and medicines

~ High societal impact (health and economic)

~ Serious outcomes of untreated disease

~ Improved outcomes with disease management

DISEASE SELECTION

HEALTHCARE IN NEW MEXICO

UNM HSC

State Health Dept

Private Practice

Community Health Centers

Hepatitis C

HIV

Hepatitis B

BUILDING BRIDGESBUILDING BRIDGES

PARETTO’S PRINCIPLE

HEALTHCARE IN NEW MEXICO

Specialists

Primary Care Pharmacist

s

Nurse Practitioners

Hepatitis C

HIV

Hepatitis B

KNOWLEDGE IMPORTANT - NOT

TITLEUse Existing Community Providers

KNOWLEDGE IMPORTANT - NOT TITLE

COMMUNITY HEALTH EXTENSION AGENT

CHEA

COMMUNITY HEALTH EXTENSION AGENT

ROLE OF KNOWLEDGE NETWORK

Learning Capacity

Time

Increasing Gap

“Expanding the Definition of Underserved Population”

A KNOWLEDGE NETWORK IS NEEDED

KNOWLEDGE MODEL

Patient specific knowledge on demand

Access to Case-Specific Information like Access to Electricity

KNOWLEDGE MODEL

Socorro

San Juan Taos

McKinley Sandoval

Los Alamos

Santa Fe

Cibola

Sierra

Grant

Luna

Hidalgo

Dona Ana

ColfaxUnion

Mora Harding

San Miguel

Bernalillo

ValenciaTorrance

Lincoln

OteroEddy

Chaves

Lea

Roosevelt

De Baca

Guadalupe

Quay

Curry

Rio Arriba

Catron

Department of CorrectionsIndian Health Service

Federally Qualified Health Centers ( FQHC )

PROJECT ECHO RURAL SITES

( IHS )Department of Health ( DOH )

Pending FQHC & IHS

8/1/06

How well has model worked? 173 HCV Telehealth Clinics have been conducted

• 3016 patients managed

CME’s/CE’s issued:2917 CME/CE hours issued to ECHO providers at no-cost.205 hours of HCV Training conducted at rural sites

6 Million Dollars of No Cost Drug ObtainedNational Recognition as Model for Complex Disease Care

KNOWLEDGE MODELRobert Wood Johnson Changemaker Award

• Applications sought for Disruptive Innovations in Healthcare – New Models that would change healthcare nationally and globally

• 307 Applications from 27 countries• 9 finalists selected by a panel of Judges• Project ECHO selected a winner by

worldwide online voting

VISION FOR THE FUTURE

Mon Tue Wed Thurs Fri

8-10 AM

Hepatitis C

Cardiac Risk Reduction Clinic

Asthma Prevention of Teenage Suicide

Mental Health Disorders

10-12 AM

Rhuema-tology

Neurology

Substance Abuse

Geriatrics

Endocrine

2-4 PM

Gastro Cardiology

HeartFailure

ChildhoodObesity

Orthopedics

28

VISION FOR THE FUTURE

Perceived Benefits to Providersscale: 1 = none or no skill at all 7= expert-can teach others

N=19 BEFORE Participation MEAN (SD)

TODAYMEAN

(SD)

PairedDifferenceMEAN

(SD)

p-value

1. Ability to identify suitable candidates for treatment for HCV.

3.2 (1.3)5.7 (0.8)

2.5 (1.0) <0.0001

2. Ability to assess severity of liver disease in patients with Hepatitis C.

3.7 (1.0)5.6 (0.8)

1.9 (0.9) 0.0001

3. Ability to treat HCV patients and manage side effects.

2.3 (1.3)5.5 (0.8)

3.2 (1.5) <0.0001

Perceived Benefits to Providers scale: 1 = none or no skill at all 7= expert-can teach others

BEFORE Participation MEAN (SD)

TODAYMEAN

(SD)

PairedDifferenceMEAN

(SD)

p-value

4. Ability to assess and manage psychiatric co-morbidities in patients with Hepatitis C.

2.7 (1.3)5.3 (0.9)

2.5 (1.4) 0.0002

5. Serve as local consultant within my clinic and in my area for HCV questions and issues.

2.8 (1.2)6.0 (0.9)

3.2 (1.3) <0.0001

Overall Competence (average of 9 items above)

3.2* (1.0)5.7* (0.6)

2.5 (1.0) <0.0001

Cronbach’s alpha for the BEFORE ratings = 0.93 and Cronbach’s alpha for the TODAY ratings = 0.90 indicating a high degree of consistency in the ratings on the 9 items

Project ECHO Annual Meeting Survey

Mean ScoreRange 1-5

Project ECHO has diminished my professional isolation

4.3

My participation in Project ECHO has enhanced my professional satisfaction

4.8

Collaboration among agencies in Project ECHO is a benefit to my clinic

4.9

Project ECHO has expanded access to HCV treatment for patients in our community

4.9

Access to in general to specialist expertise and consultation is a major area of need for you and your clinic

4.9

Access to HCV specialist expertise and consultation is a major are of need for you and your clinic

4.9

September 23, 2006

Objectives-Disease OutcomesTo show that hepatitis C treatment delivered through Project ECHO is as safe and effective as care given at the University of New Mexico

To show that Project ECHO improves delivery of hepatitis C care to minority populations

To compare treatment outcomes for minority and non-Hispanic white subjects

MethodsStudy design:– Prospective cohort study– Site effect adjusted for patient covariates

Study sites– Project ECHO

14 community clinicsNM Department of Corrections

– University of New Mexico Liver Clinic

Subjects: referred by their primary care providers

Interim Results

Group Number Percent *

All patients 488

Enrolled to trial 348 71.3%

Treatment ended 240 69.0%

Full course of treatment 134 55.8%

6-month follow-up 78 58.2%

Sustained viral response 67 85.9%

* Of the preceding row

ECHO Sites Serve Minorities

ECHO UNM P-value

Minorities 66.5% 49.4% 0.010

Hispanics 57.4% 36.5% 0.002

Outcomes by Site

ECHO UNM P-value

Non-response 21.9% 15.3% NS

SAE* 8.2% 25.4% 0.003

* Excludes subjects stopping treatment for other reasons

Outcomes by Minority Status

Minority NHW P-value

Non-response 22.8% 14.7% NS

SAE* 15.1% 14.9% NS

* Excludes subjects stopping treatment for other reasons

Factors Affecting Response

Variable Non-response (n=47)

All others (n=193)

P-value

Genotype 1 85.1% 51.8% <0.001

SGOT 85 ± 54 66 ± 48 0.013

Uric Acid 6.7 ± 1.8 6.0 ± 1.7 0.034

Platelets 168 ± 73 196 ± 78 0.031

MCV 92 ± 5 91 ± 5 0.024

Factors Affecting SAE

Variable SAE (n=24)

Rx Completed (n=136)

P-value

Age (years) 48.9 ± 9.7 44.7 ± 9.7 0.042

Women 70.8% 39.0% 0.004

High school 45.8% 69.1% 0.027

IV drug use 33.3% 57.4% 0.030

Liver disease 37.5% 15.4% 0.011

Depression 58.3% 33.8% 0.022

Factors Affecting SAE

Variable SAE (n=24)

Rx Completed (n=136)

P-value

Albumin 3.87 ± 0.52 4.16 ± 0.41 0.015

Creatinine 0.78 ± 0.16 0.95 ± 0.18 0.001

Hgb 14.9 ± 1.4 15.6 ± 1.4 0.022

Hct 42.6 ± 4.3 45.0 ± 4.0 0.010

RBC 4.63 ± 0.55 5.02 ± 0.95 0.004

Disease Outcome ConclusionsProject ECHO provides hepatitis C treatment that is

as safe as care delivered at UNMPreliminary data suggests that Project ECHO delivers

hepatitis C treatment that is just as effectiveProject ECHO treats a larger proportion of minorities

than UNMThe outcomes of treatment for minority and non-

Hispanic white subjects are similar

Supported by Agency for Health Research and Quality grant 1 UC1 HS015135-03 and New Mexico Legislature

Use of telemedicine, best practice protocols, co-management of patients with case based learning (the ECHO model) is a robust method to to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.